点选式电子病历在治疗甲型HIN1流感中的应用

The Clinical Application of Point-and-Click Type Electronic Medical Records in the Type A H1N1 Influenza Cases

目的分析点选式电子病历在治疗甲型H1N1流感病例中的应用情况，了解其优势与不足。方法，选取2009年4月-7月北京佑安医院收治的甲型H1N1流感纸质病历117份，2009年7月～8月收治的甲型H1N1流感电子病历127份。对现病史中甲型H1N1流感常见症状发热、流涕、咳嗽、咳痰的描述情况进行统计，分析点选式电子病历与传统手写病历规范化差别。结果对发热的表现、最高体温、是否伴随畏寒、寒颤等因素进行记录，显示电子病历明显优于手写病历（P〈0．05）。结论点选式电子病历较传统手写病历对甲型H1N1流感病史收集记录更加全面、规范。

Objective To analyze the clinical application of point - and - click type electronic medical records in the type A H1N1 influenza cases. Method 117 handwritten medical records for type A H1N1 influenza cases from April 2009 to July 2009 and select 197 electronic medical records of type A HI N1 influenza cases from July 2009 to August 2009 in Beijing You＇an hospital were recruited. The descriptions of common symptoms of type A H1N1 influenza were analyzed statistically. Result The descriptions of common symptoms of type A H1N1 influenza, such as fever, the highest temperature, chills description, fever type, nasal discharge, cough frequency, expectoration odor description and sputum volume, in electronic medical records were more standard- ized than that in hand - written medical records （ P 〈 0.05 ）. Conclusion The point - and - click type electronic medical records is more comprehensive and standardized in the process of history collection for the type A H1N1 influenza cases.